Wellness: Gout Steps Out

As if we didn’t have enough fretting from medical experts about this or that affliction “‘increasingly” tormenting patients,”more and more” prevalent among us, now it’s gout.

In the U.S., the number of adults suffering from gout more than doubled between the 1960s and the 1990s, according to the American College of Rheumatology (ACR), and it doubled again from the early 1990s to 2008, and that’s a pain. Literally.

Gout happens when the uric acid that occurs naturally in the blood gets too thick and crystallizes like thousands of tiny needles in the joints, most commonly devastating the “bunion joint” where the big toe connects into the foot.

It used to seem like a quaint disease of yesteryear, an affliction commonly associated with kings and nobles of the olden days, usually pictured sitting back with one of their feet wrapped thickly in white cloth and propped on a footstool.

Now it seems like everybody knows somebody with gout, if they don’t have it themselves. Bill had gout so bad he couldn’t walk, at least until he started taking expensive medicines to control it. Bill is 80, but Dave is only 24, and he had it bad too, with a foot almost too painful to touch the floor.

What the heck is going on?

One clue is that while gout has been spreading in the U.S. population, so has obesity: the median percentage of the U.S. population that is obese increased by 74 percent from 1995 to 2010, according to the Centers for Disease Control (CDC). More than 80 percent of people with gout are overweight or obese.

In those olden-days images of the upper class suffering from gout, poor people tended to be thin and rich people tended to be fat.

“Gout, unlike any other disease, kills more rich men than poor,” said Thomas Sydenham, a 17th-century physician who has been called “the father of English medicine.”

Not any more. Nowadays, in fact, the richer you are, the thinner you are likely to be. A 2004 study out of Ohio State University indicated that, on average, the net worth of obese people was about half what it was for people with what the Center for Disease Control calls “healthy weight.”

“More and more,” as they say, gout is attacking those who can least afford the fancy medicines and treatments to control it.

Obesity is not the only risk factor, of course. We all struggle with weight loss. It can be a losing battle, and even if we win it can take a long time. People can make other lifestyle changes more quickly and simply, people like the aforementioned Dave, for example, who may be younger and less heavy than Bill, but does drink a good deal more than some would consider wholesome.

“I would say that the first priority would be to stop all beer consumption,” says Dr. Theodore Fields, Professor of Clinical Medicine at Weill Cornell Medical College in New York. “All types of alcohol decrease people’s ability to get rid of uric acid in the urine, but beer also has a high purine content.”

Purine is natural in the body as well as in many foods, and the natural metabolic breakdown of purine produces uric acid. It has been estimated that a heavy drinker might get gout five years sooner than he might if he wasn’t a drinker, says Dr. Fields.

Even moderate consumption of beer is associated with a high risk of developing gout, according to a Harvard Medical School study. Alcohol “spirit beverages” have a significant but lower risk, according to the study and, joy to all vinophiles, moderate wine consumption, one to two glasses per day, showed no significant effect on gout incidence.

Beer purines may be a significant source of uric acid in the body, but beer is not the only high-purine drink or food to avoid. These also include red meat; shell fish and seafood such as anchovies, sardines in oil, and caviar; organ meats like liver; even some seemingly healthy vegetables like mushrooms, spinach and asparagus; and regular (not diet) sweetened sodas.

“The regularly sweetened sodas increase uric acid because of the effect of their large content of high-fructose corn syrup,” says Fields.

Fructose is the only carbohydrate known to increase uric acid levels, according to the British Medical Journal, which reported a study in the U.S. and Canada showing that the risk of gout in men was 85 percent higher among those who sucked down two or more sugar-sweetened soft drinks per day compared to those who drank less than one per month.

In women, reports the ACR, a similar study found those drinking two or more sugary soft drinks per day were 2.4 times more likely to have gout. Interestingly, the same risk factor accompanied the drinking of orange juice, the study found.

Adolescents are the largest consumers of sugar-sweetened sodas and other beverages, including many fruit juices we think are healthy alternatives. Of adolescents, 62 percent drink at least one sugary beverage per day, representing 39 pounds of sugar per year.

They may be kids now, but uric acid can build up in the joints for years. Men can start having gout in their 20s, says Fields, although women usually don’t get gout until after menopause (estrogen increases the excretion of uric acid).

The aging of the population, of course, is an additional reason why gout incidence has increased. Part of that is the decline with age of kidney function, and the resulting decline in the body’s ability to get rid of uric acid, says Dr. Eric Matteson, who chairs the communications and marketing committee of the American College of Rheumatology. High blood pressure medications also affect the way the body gets rid of uric acid.

Just as many pathologies affect the ability to control uric acid, uric acid also promotes many pathologies. Evidence suggests that uric acid can contribute to cardiovascular disease, high blood pressure and kidney disease, for example. Johns Hopkins researchers have found that high uric acid in the blood may cause the “barely detectable mini strokes that potentially contribute to mental decline in aging adults.”

Besides lifestyle changes, a host of other approaches to preventing or reducing the incidence and severity of gout attacks are bandied about. Simply drinking more water can help prevent gout attacks, according to studies reported by the ACR. Drinking skim milk, in one study, reduced serum uric acid by 10 percent, while drinking soy milk increased it by 10 percent. Vitamin C intake is also associated with lower risk of gout in men.

And what about the currently popular belief that drinking tart cherry juice prevents gout? Dave, for example, the 24-year-old man mentioned at the beginning of this article, swears that heavy drinking of tart cherry juice got rid of his gout.

One study did indeed show that cherry juice lowered the uric acid in the blood, according to Dr. Fields, although not much, not enough to make a big difference for most patients.

“It has been found that some types of cherries lower the uric acid more than others and that it appears to relate to the vitamin C content of the cherries,” says Dr. Fields. “We already have studies showing a similar level of lowering of uric acid by taking 500mg of vitamin C. I don’t routinely advise this to patients before they see their physician, because 10 percent of gout patients are at risk of kidney stone, and increasing the uric acid in the urine could increase the kidney stone risk.”

While lifestyle and diet changes and self-administered therapies such as water-sipping may have value, once gout attacks and hits hard, modern doctors can hit back with a number of medicines: Allopurinal and Uloric, for example, which help reduce production of uric acid; Probenecid, which increases the kidney’s ability to excrete uric acid; and Colchicine, aimed mainly at preventing the inflammation that results from gout.

Certainly, not everybody will get gout.

“People need to understand that gout is a genetic disease,” says Dr. Fields. “Ninety percent of people with gout have a genetic defect which causes them to be unable to put enough uric acid into the urine, so it builds up in the body. Ten percent have a genetic defect that causes them to make too much uric acid, with the same end effect. If someone doesn’t have either of those defects, they will generally not get gout, regardless of what they eat.”

The trouble is, of course, that our genetic propensity for getting gout is not something any of us know up front. Healthy living is not a bad idea for everyone, and for those who begin to experience gout symptoms or have gout running in the family, what we know about gout-averse lifestyle and diet is a good place to start. And of course, sigh, the always-important battle of the bulge.

A lot more has been learned about the effects of what we eat and drink on giving us gout, “but those things are so tied in with obesity that you can’t separate those things out,” says Dr. Matteson.

“If there’s one single thing we can concentrate on,” he says, “it would be reducing obesity.”